Alert: Potential Changes to Reimbursement for Anesthesia Sedation in Pain Management Injections

According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain management procedures require only local anesthesia under most routine circumstances, these include:

  • Epidural steroid injections
  • Epidural blood patch
  • Trigger point injections
  • Sacroiliac joint injections
  • Bursal injections
  • Occipital nerve block
  • Facet injections

Because of this, general anesthesia and moderate sedation services (CPT codes 00300, 00400, 00600, 01935-01936, 01991-01992, 99152-99153, 99156-99157) billed with pain management services (CPT codes 20552, 20553, 27096, 62273, 62320-62323, 64405, 64479, 64480, 64483, 64484, 64490-64495, 0228T, 0229T, 0230T, 0231T, G0260) for a patient age 18 or older will be denied.

When conscious sedation is provided during the performance of a pain procedure, the patient should be responsive during critical portions of the pain management therapy. For a limited number of patients, a second provider may be required to manage moderate or deep sedation, or in special cases, other anesthesia services during the interventional pain therapy. 

The pain management therapies described above are not considered typical primary procedures to warrant the use of deep sedation or anesthesia. However, providers may appeal with medical documentation to substantiate the need to use general anesthesia and moderate sedation in addition to the local anesthesia.

 

Anesthesia Sedation Criteria

Anesthesia sedation for adults undergoing an interventional pain management procedure is considered medically necessary when EITHER the interventional pain procedure requires the individual to remain motionless for a prolonged period or in a painful position (e.g., sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device) OR both of the following criteria are met: 

 

One of the following interventional pain procedures is being performed: 

  • epidural steroid injection 
  • epidural blood patch 
  • facet joint injection 
  • peripheral and/or spinal nerve root block 
  • sacroiliac joint injection 

 

 

And there is a presence of ANY of the following: 

  • Increased risk for complications due to ASA physical status III or above 
  • Any of the following comorbidities that increase risk for complications: 
    • severe cardiac disease and/or pulmonary disease (e.g., severe hypotension [systolic < 90mm hg, major cardiac dysfunction) 
    • documented sleep apnea 
    •  morbid obesity (body mass index [BMI] greater than or equal to 40 kg/m2) 
    • chronic renal failure [GRF < 60ml/min for more than 3 months or stage 3A] 
    • chronic liver disease [end stage liver disease score >10] 
    • age > 70 years 

 

  • Severe anxiety under active medical management with psychotropic medication and/or cognitive therapy, or other severe psychiatric condition(s), or severe cognitive impairment(s) that would risk putting the individual’s safety at risk during the planned procedure 
  • Spasticity or movement disorder (e.g., cerebral palsy, dystonia, brain injury, stroke) 
  • Individuals at risk of airway obstruction due to anatomical variation (e.g., neck mass, jaw abnormality, abnormality of the oral cavity, neck tumor, neck edema, tracheal deviation) 
  • Anticipated tolerance or physical dependence to sedatives/monitored sedation (e.g., chronic opioid or benzodiazepine use) 
  • History of or active illicit drug or alcohol abuse 

 

Correct documentation is critical for appeals and getting claims paid. For any questions, or more information on anesthesia coding and billing support, contact us today! 

 

Read more about a draft LCD for epidural procedures here!